Hospital competition and the expenses for treatments of acute and non-acute common diseases: evidence from China

Abstract Background Because there is heterogeneity in disease types, competition among hospitals could be influenced in various ways by service provision for diseases with different characteristics. Limited studies have focused on this matter. This study aims to evaluate and compare the relationships between hospital competition and the expenses of prostatectomies (elective surgery, representing treatments of non-acute common diseases) and appendectomies (emergency surgery, representing treatments of acute common diseases). Methods Multivariable log-linear models were constructed to determine the association between hospital competition and the expenses of prostatectomies and appendectomies. The fixed-radius Herfindahl-Hirschman Index was employed to measure hospital competition. Results We collected data on 13,958 inpatients from the hospital discharge data of Sichuan Province in China from September to December 2016. The data included 3578 prostatectomy patients and 10,380 appendectomy patients. The results showed that greater competition was associated with a lower total hospital charge for prostatectomy (p = 0.006) but a higher charge for appendectomy (p < 0.001). The subcategory analysis showed that greater competition was consistently associated with lower out-of-pocket (OOP) and higher reimbursement for both surgeries. Conclusions Greater competition was significantly associated with lower total hospital charges for prostatectomies, while the opposite was true for appendectomies. Furthermore, greater competition was consistently associated with lower OOP but higher reimbursement for both surgeries. This study provides new evidence concerning the heterogeneous roles of competition in service provision for non-acute and acute common diseases. The findings of this study indicate that the pro-competition policy is a viable option for the Chinese government to relieve patients’ financial burden (OOP). Our findings also provide references and insights for other countries facing similar challenges.

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A cost analysis of managing cancer-related pain among hospitalized US cancer patients.

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.15_suppl.7079 ◽

2020 ◽

Vol 38 (15_suppl) ◽

pp. 7079-7079

Author(s):

Olatunji B. Alese ◽

Chao Zhang ◽

Katerina Mary Zakka ◽

Sungjin Kim ◽

Christina Wu ◽

...

Keyword(s):

Pain Management ◽

Hospital Stay ◽

Cancer Patients ◽

Metastatic Cancer ◽

Hospital Charge ◽

Hospital Charges ◽

Total Charge ◽

Total Hospital ◽

Total Hospital Charge ◽

The Cost

7079 Background: Pain is a common symptom of cancer, affecting patients' function and quality of life. It is also a common cause of hospitalization for cancer patients. The aim of this study was to evaluate the cost of in-hospital pain management among US cancer patients. Methods: A retrospective analysis of data from all US hospitals that contributed to the National Inpatient Sample for 2011-2015 was conducted. All cancer patients admitted for pain management were included in the analysis. Main outcomes were factors significantly associated with hospital length of stay, total charge per hospital stay, and in-hospital mortality. Weighted chi-square test was used for categorical covariates and univariate analysis was performed using a logistic model. Results: 122,776 patient discharges were identified. Mean age was 59.3 years and 52.3% were female. 65.9% stayed in the hospital for longer than 72 hours, with a median total hospital charge of $48,156. Conversely, the median total hospital charge for those spending less than 72 hours on admission was $15,966. Median total charge per hospital stay was similar among insured and uninsured/self-pay patients ($32,879 vs. $32,323; p=0.013), but higher in patients without metastatic disease ($33,315 vs. $29,369; p<0.001). It was also higher in those with the highest income quartile when compared with lowest income patients ($38,223 vs. $30,047; p<0.001). Co-morbid medical illnesses were more prevalent in those with longer hospital stay (15 vs. 12; p<0.001) and the overall in-hospital mortality rate was 8.2%. There was no significant difference in median total hospital charges between those who died in, or those discharged from the hospital ($33,746 vs. $32,795; p<0.001). On multivariate analyses, gender, race, insurance status, diagnosis of metastatic cancer, age, number of co-morbid medical illnesses, year of diagnosis, and median income were significant predictors of length of stay. Race, insurance payor, metastatic cancer, age, and number of co-morbid medical illnesses were significant predictors of total hospital charges, after adjusting for other covariates. Conclusions: In-patient pain management of cancer patients is associated with significant health care costs. Optimization of outpatient pain management strategies could significantly lower the cost of care for cancer.

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Diabetes Does Not Worsen Outcomes of Patients Admitted for Hyperthyroidism: Analysis of the National Inpatient Sample

Journal of the Endocrine Society ◽

10.1210/jendso/bvab048.835 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

pp. A410-A410

Author(s):

Hafeez Shaka ◽

Emmanuel Akuna ◽

Dimeji Olukunmi Williams ◽

Iriagbonse Asemota ◽

Ehizogie Edigin ◽

...

Keyword(s):

Linear Regression Analysis ◽

The United States ◽

Hospital Charge ◽

Hospital Length Of Stay ◽

Hospital Charges ◽

Secondary Diagnosis ◽

National Inpatient Sample ◽

Inpatient Mortality ◽

Total Hospital ◽

Total Hospital Charge

Abstract Introduction: Both diabetes mellitus (DM) and hyperthyroidism are common diseases. However, it is unclear if co-existing DM worsens outcomes in patients with hyperthyroidism. This study aims to compare the outcomes of patients primarily admitted for hyperthyroidism with and without a secondary diagnosis of DM. Methods: Data were extracted from the National Inpatient Sample (NIS) 2016 and 2017 Database. NIS is the largest inpatient hospitalization database in the United States. The NIS was searched for hospitalizations for adult patients with hyperthyroidism as principal diagnosis with and without DM as secondary diagnosis using ICD 10 codes. The primary outcome was inpatient mortality. Hospital length of stay (LOS), total hospital charges and NSTEMI were secondary outcomes of interest. Multivariate logistic and linear regression analysis was used accordingly to adjust for confounders. Results: There were over 71 million hospitalizations in the combined NIS 2016 and 2017 database. Out of 17,705 hospitalizations for hyperthyroidism, 2,160 (15.9%) had DM. Hospitalizations for hyperthyroidism with DM had similar inpatient mortality [0.35% vs 0.50%, AOR 0.25, 95% CI (0.05–1.30), P= 0.101], total hospital charge [$47,001 vs $36,978 P=0.220], LOS [4.50 vs 3.48 days, P=0.050] and NSTEMI compared to those without DM. Conclusion: Hospitalizations for hyperthyroidism with DM had similar inpatient mortality, total hospital charges, LOS and odds of undergoing ablation compared to those without obesity.

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Vertebroplasty and kyphoplasty in the USA from 2004 to 2017: national inpatient trends, regional variations, associated diagnoses, and outcomes

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-016733 ◽

2020 ◽

pp. neurintsurg-2020-016733

Author(s):

Nima Hafezi-Nejad ◽

Christopher R Bailey ◽

Alex J Solomon ◽

Moustafa Abou Areda ◽

John A Carrino ◽

...

Keyword(s):

New England ◽

Financial Burden ◽

Hospital Charges ◽

Total Hospital ◽

Average Hospital ◽

Regional Variations ◽

The Pacific ◽

The Usa ◽

Procedural Complications ◽

History Of

BackgroundTo explore the national inpatient trends, regional variations, associated diagnoses, and outcomes of vertebral augmentation (vertebroplasty and kyphoplasty) in the USA from 2004 to 2017.MethodsData from the National Inpatient Sample were used to study hospitalization records for percutaneous vertebroplasty and kyphoplasty. Longitudinal projections of trends and outcomes, including mortality, post-procedural complications, length of stay, disposition, and total hospital charges were analyzed.ResultsFollowing a period of decreased utilization from 2008 to 2012, hospitalizations for vertebroplasty and kyphoplasty plateaued after 2013. Total hospital charges and overall financial burden of hospitalizations for vertebroplasty and kyphoplasty increased to a peak of $1.9 billion (range $1.7–$2.2 billion) in 2017. Overall, 8% of procedures were performed in patients with a history of malignancy. In multivariable modeling, lung cancer (adjusted OR (aOR) 2.6 (range 1.4–5.1)) and prostate cancer (aOR 3.4 (range 1.2–9.4)) were associated with a higher risk of mortality. The New England region had the lowest frequency of routine disposition (14.1±1.1%) and the lowest average hospital charges ($47 885±$1351). In contrast, 34.0±0.8% had routine disposition in the West Central South region, and average hospital charges were as high as $99 836±$2259 in the Pacific region. The Mountain region had the lowest number of procedures (5365±272) and the highest mortality rate (1.2±0.3%).ConclusionNational inpatient trends of vertebroplasty and kyphoplasty utilization remained stable after a period of decline from 2008 to 2012, while the financial burden of hospitalizations increased. Despite recent improvements in outcomes, significant regional variations persisted across the USA.

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Cancer-Related Pain Is an Independent Predictor of In-Hospital Opioid Overdose: A Propensity-Matched Analysis

Pain Medicine ◽

10.1093/pm/pnz130 ◽

2019 ◽

Vol 20 (12) ◽

pp. 2552-2561 ◽

Cited By ~ 1

Author(s):

Nnaemeka E Onyeakusi ◽

Fahad Mukhtar ◽

Semiu O Gbadamosi ◽

Adebamike Oshunbade ◽

Adeyinka C Adejumo ◽

...

Keyword(s):

Length Of Stay ◽

Postoperative Pain Management ◽

Hospital Charge ◽

Primary Objective ◽

Hospital Charges ◽

Opioid Overdose ◽

Inpatient Mortality ◽

Total Hospital ◽

Total Hospital Charge ◽

Secondary Objective

Abstract Background About 50% of patients with cancer who have undergone surgery suffer from cancer-related pain (CP). The use of opioids for postoperative pain management presents the potential for overdose, especially among these patients. Objective The primary objective of this study was to determine the association between CP and postoperative opioid overdose among inpatients who had undergone major elective procedures. The secondary objective was to assess the relationship between CP and inpatient mortality, total hospital charge, and length of stay in this population. Methods Data of adults 18 years and older from the National Inpatient Sample (NIS) were analyzed. Variables were identified using ICD-9 codes. Propensity-matched regression models were employed in evaluating the association between CP and outcomes of interest. Results Among 4,085,355 selected patients, 0.8% (N = 2,665) had CP, whereas 99.92% (N = 4,082,690) had no diagnosis of CP. We matched patients with CP (N = 2,665) and no CP (N = 13,325) in a 1:5 ratio. We found higher odds of opioid overdose (adjusted odds ratio [aOR] = 4.82, 95% confidence interval [CI] = 2.68–8.67, P < 0.0001) and inpatient mortality (aOR = 1.39, 95% CI = 1.11–1.74, P = 0.0043) in patients with CP vs no CP. Also, patients with CP were more likely to stay longer in the hospital (12.76 days vs 7.88 days) with higher total hospital charges ($140,220 vs $88,316). Conclusions CP is an independent risk factor for opioid overdose, increased length of stay, and increased total hospital charges.

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Lung involvement in systemic sclerosis is associated with adverse hospital outcomes: insights from the National Inpatient Sample

Journal of Investigative Medicine ◽

10.1136/jim-2020-001743 ◽

2021 ◽

pp. jim-2020-001743

Author(s):

Jesse Osemudiamen Odion ◽

Armaan Guraya ◽

Chukwudi Charles Modijeje ◽

Osahon Nekpen Idolor ◽

Eseosa Jennifer Sanwo ◽

...

Keyword(s):

Systemic Sclerosis ◽

Hospital Charge ◽

Hospital Length Of Stay ◽

Lung Involvement ◽

National Inpatient Sample ◽

Inpatient Mortality ◽

Total Hospital ◽

Total Hospital Charge ◽

Icd 10 ◽

Secondary Outcomes

This study aimed to compare outcomes of systemic sclerosis (SSc) hospitalizations with and without lung involvement. The primary outcome was inpatient mortality while secondary outcomes were hospital length of stay (LOS) and total hospital charge. Data were abstracted from the National Inpatient Sample (NIS) 2016 and 2017 database. This database is the largest collection of inpatient hospitalization data in the USA. The NIS was searched for SSc hospitalizations with and without lung involvement as principal or secondary diagnosis using International Classification of Diseases 10th Revision (ICD-10) codes. SSc hospitalizations for patients aged ≥18 years from the above groups were identified. Multivariate logistic and linear regression analysis was used to adjust for possible confounders for the primary and secondary outcomes, respectively. There were over 71 million discharges included in the combined 2016 and 2017 NIS database. 62,930 hospitalizations were for adult patients who had either a principal or secondary ICD-10 code for SSc. 5095 (8.10%) of these hospitalizations had lung involvement. Lung involvement group had greater inpatient mortality (9.04% vs 4.36%, adjusted OR 2.09, 95% CI 1.61 to 2.73, p<0.0001), increase in mean adjusted LOS of 1.81 days (95% CI 0.98 to 2.64, p<0.0001), and increase in mean adjusted total hospital charge of $31,807 (95% CI 14,779 to 48,834, p<0.0001), compared with those without lung involvement. Hospitalizations for SSc with lung involvement have increased inpatient mortality, LOS and total hospital charge compared with those without lung involvement. Collaboration between the pulmonologist and the rheumatologist is important in optimizing outcomes of SSc hospitalizations with lung involvement.

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Characterizing Firearm Assault Injury Among Young Black Men Using Arkansas Hospital Discharge Data

Journal of Interpersonal Violence ◽

10.1177/0886260521997947 ◽

2021 ◽

pp. 088626052199794

Author(s):

Nakita N. Lovelady ◽

Nickolas D. Zaller ◽

Mary Kate Stewart ◽

Ann M. Cheney ◽

Austin Porter III ◽

...

Keyword(s):

Hospital Discharge ◽

Black Men ◽

Hospital Discharge Data ◽

Hospital Charges ◽

Health Care Information ◽

Discharge Data ◽

Patient Demographics ◽

Predicting Factors ◽

Drug Use Disorders ◽

Care Information

Using statewide hospital discharge data from 2005 to 2014, this study aimed to describe and identify predictors of firearm assault among young Black men ages 18 to 44 in Arkansas. Descriptive analyses of data were performed for patient demographics (age, marital status, residential location, etc.), injury, and health care information (hospital charges, length of stay, mortality, time, day and season of injury, etc.). Logistic regression analysis was performed to identify significant predicting factors for firearm assault among this population. Most of the sample survived firearm assault injury, were ages 18–35, were not married, resided in Central Arkansas, and were admitted to a Central Arkansas hospital during night hours on weekends. The majority had a short hospital stay, and total charges exceeded $34 million during the study observation years. Most patients had no diagnosis of a mental disorder, and a little less than half had drug use disorders. Being ages 18–25, living in the Central region of Arkansas, and being married were all significant predictors of firearm assault for this population. Death was also significantly associated with firearm assault. Our findings lay the groundwork for understanding firearm assault injury among young Black men in Arkansas. Research should be expanded to examine other important data sources for firearm assault and to further explore the context of predicting factors, in order to provide a more comprehensive understanding of firearm assault and to better inform future prevention efforts.

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291 Pre-Operative Venepuncture: An Audit of The Trauma and Orthopaedic Department at The Royal Sussex County Hospital, Brighton

British Journal of Surgery ◽

10.1093/bjs/znab134.398 ◽

2021 ◽

Vol 108 (Supplement_2) ◽

Author(s):

H Harris ◽

T Antonio ◽

A Hagiga ◽

D Crone

Keyword(s):

Major Trauma ◽

Elective Surgery ◽

Financial Burden ◽

Trauma Patients ◽

Minor Trauma ◽

Inclusion Criteria ◽

Blood Testing ◽

Orthopaedic Department ◽

Minor Surgery ◽

Routine Coagulation

Abstract Background NICE recommends that patients undergoing intermediate or minor elective surgery do not need routine coagulation or transfusion blood testing unless they are ASA 3+ or taking anticoagulation mediation, where testing may be considered. Currently there is no guidance for trauma patients. Method We identified all patients that underwent intermediate or minor trauma and orthopaedic surgery within a three-month period from December 2019- February 2020 at the RSCH. We excluded major trauma patients, patients taking anticoagulants and patients with complex admission or past medical history. Computer records were used to identify pre-operative investigations and admission history. Results 843 patients met our inclusion criteria. In total, 92 clotting studies and 200 transfusion samples were taken preoperatively. The majority of tests were for patients undergoing ankle 130/292 (45%) or Tibia/Fibula 54/292 (18%) procedures. This equates to approximately 1168 blood tests per year. Based on the lab cost of £15.97 for a transfusion sample and £18 for a coagulation sample, this is a cost of approximately £19,616 each year on blood testing that is not indicated. Discussion We hope that by presenting these results we will help reduce the unnecessary time and financial burden of routine venipuncture in departments undertaking intermediate and minor surgery.

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Abstract WP355: Intracerebral Hemorrhage Care in a Stroke Unit is Safe and Associated With Lower Costs

Stroke ◽

10.1161/str.47.suppl_1.wp355 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Corey R Fehnel ◽

Linda C Wendell ◽

N. Stevenson Potter ◽

Kimberly Glerum ◽

Richard N Jones ◽

...

Keyword(s):

Intracerebral Hemorrhage ◽

Stroke Unit ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Hospital Charges ◽

Total Hospital ◽

Reduced Costs ◽

Reducing Costs ◽

Ich Score ◽

Median Hospital

Background: There is little data to support level of care decisions for lower risk intracerebral hemorrhage (ICH) patients. The addition of a dedicated stroke unit (SU) at our institution allowed for a comparison of such patients cared for in the intensive care unit (ICU) or SU. We hypothesized that SU care of select ICH patients would not change functional outcome, and result in reduced costs. Methods: Two retrospective cohorts of consecutive patients with small (<20 cc) supratentorial ICH and the absence of anticoagulation were enrolled. In the first study period from August 1, 2008 to February 1, 2011, patients were admitted to the neurological or medical ICU (historical control). In the second study period from August 1, 2012 to January 30, 2014, patients were admitted to a dedicated SU. Intubated patients, those requiring vasopressors, osmotic therapy, or ventriculostomy were excluded. Primary outcomes were discharge modified Rankin Score (mRS) and total hospital charges. Multivariate analyses were used for predicting mRS and early complications. Results: There were 104 patients included in the analysis (41 ICU, 63 SU). Mean age, gender and race did not differ significantly between groups. Mean ICH volume was 6cc in the SU group and 8cc in the ICU group (P>.05). Prior antiplatelet use, ICH location, and ICH score did not differ between groups. Intraventricular hemorrhage and hydrocephalus were more common in the ICU group (P<.001). Two SU patients transferred to the ICU for pneumonia and acute myocardial infarction. There were no significant differences in complications such as ICH expansion, use of osmotic therapy, seizures, or pneumonia. There was no difference in discharge mRS between groups (P>.05). Median hospital length of stay was 6 days in the ICU group and 3 days in SU group (P<.001). Median direct costs for the ICU group were $5,859 (IQR 4,782-9,733) and were $4,078 (IQR 2,861-6,865) for the SU group (P<.001). Unit of admission was not a significant predictor of early complication (P=.73) or discharge mRS (P=.43) in multivariate analysis. Conclusions: This preliminary retrospective study provides support for select low-risk ICH patients to be safely cared for in a lower intensity setting with potential for reducing costs.

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Prescription Opioid Abuse: Gleaning insights from hospital and vital records data

Online Journal of Public Health Informatics ◽

10.5210/ojphi.v9i1.7723 ◽

2017 ◽

Vol 9 (1) ◽

Author(s):

Reka Sundaram-Stukel ◽

Ousmane Diallo ◽

Benjamin Wiseman ◽

Richard E. Miller

Keyword(s):

Mental Health ◽

Prescription Drug ◽

Prescription Drugs ◽

The United States ◽

Hospital Charges ◽

Prescription Opioids ◽

Opioid Prescription ◽

Discharge Data ◽

Operative Recovery ◽

The Impact

ObjectiveIn this paper we used hospital charges to assess costs incurred dueto prescription drug/opioid hospitalizationsIntroductionThere is a resurgence in the need to evaluate the economic burdenof prescription drug hospitalizations in the United States. We used theWisconsin 2014 Hospital Discharge data to examine opioid relatedhospitalization incidence and costs. Fentanyl, a powerful syntheticopioid, is frequently being used for as an intraoperative agent inanesthesia, and post-operative recovery in hospitals. According to a2013 study, synthetic Fentanyl is 40 times more potent than heroinand other prescription opioids; the strength of Fentanyl leads tosubstantial hospitalizations risks. Since, 1990 it has been availablewith a prescription in various forms such as transdermal patches orlollipops for treatment of serious chronic pain, most often prescribedfor late stage cancer patients. There have been reported fatal overdosesassociated with misuse of prescription fentanyl. In Wisconsin numberof total opioid related deaths increased by 51% from 2010 to 2014with the number of deaths involving prescription opioids specificallyincreased by 23% and number of deaths involving heroin increasedby 192%. We hypothesized that opioids prescription drugs, as a proxyof Fentanyl use, result in excessive health care costs.MethodsOpioid hospitalizations was defined as any mention of the ICD9codes (304,305) in any diagnostic field or the mention of (:E935.09) onthe first listed E-code. Our analysis used the Heckman 2-stage model,a method often used by Economists in absence of randomized controltrials. In presence of unobserved choice, for example opioid relatedhospitalizations, there usually is a correlation between error in anunderlying function (fentanyl prescription) and an estimated function(hospital charges) that introduces a selection bias. Heckman treats thiscorrelation between errors as an omitted variable bias. Therefore, weestimate a Heckman two step model using hospitalization: where theselection function is the probability of being hospitalized for syntheticopioid via logistic regression. Finally, we estimate the hospitalcharges realized if the patient was given opioids.ResultsMale patients are significantly more likely to be hospitalized foropioids than are female patients; while white patients are significantlymore likely to be admitted for opioid usage than other racialgroups. We also find that comorbid factors, such as mental health,significantly impact hospital charges associated with opioid use. Wefind that persons with private health insurance are associated withhigher rates of opioid use.ConclusionsUsing a Heckman two step approach we show that comorbidconditions such as mental health, Hepatitis C, injuries, etc significantlyaffect hospital charges associated with hospitalization. We usethese findings to explore the impact of the 2013 rule mandatingdoctors share opioid prescription information on the incidence ofopioid related death and hospital charges associated with opioidprescriptions. This work is policy relevant because alternatives toopioid prescription such as meditation, pain management therapiesmay be relevant.

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Heterogeneous effects of hospital competition on inpatient expenses: an empirical analysis of diseases grouping basing on conditions’ complexity and urgency

BMC Health Services Research ◽

10.1186/s12913-021-07331-1 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Liyong Lu ◽

Xiaojun Lin ◽

Jay Pan

Keyword(s):

Regression Model ◽

Patient Flow ◽

Statistical Significance ◽

Healthcare Delivery ◽

Hospital Competition ◽

Process Of Care ◽

Healthcare Delivery System ◽

Discharge Data ◽

Heterogeneous Effects ◽

Hospital Administrative

Abstract Background Multiple pro-competition policies were implemented during the new round of healthcare reform in China. Differences in conditions’ complexity and urgency across diseases associating with various degrees of information asymmetry and choice autonomy in the process of care provision, would lead to heterogeneous effects of competition on healthcare expenses. However, there are limited studies to explore it. This study aims to examine the heterogeneous effects of hospital competition on inpatient expenses basing on disease grouping according to conditions’ complexity and urgency. Methods Collecting information from discharge data of inpatients and hospital administrative data of Sichuan province in China, we selected representative diseases. K-means clustering was used to group the selected diseases and Herfindahl-Hirschman Index (HHI) was calculated based on the predicted patient flow to measure the hospital competition. The log-linear multivariate regression model was used to examine the heterogeneous effects of hospital competition on inpatient expenses. Results We selected 19 representative diseases with significant burdens (more than 1.1 million hospitalizations). The selected diseases were divided into three groups, including diseases with highly complex conditions, diseases with urgent conditions, and diseases with less complex and less urgent conditions. For diseases with highly complex conditions and diseases with urgent conditions, the estimated coefficients of HHI are mixed in the direction and statistical significance in the identical regression model at the 5% level. For diseases with less complex and less urgent conditions, the coefficients of HHI are all positive, and almost all of them significant at the 5% level. Conclusions We found heterogeneous effects of hospital competition on inpatient expenses across disease groups: hospital competition does not play an ideal role in reducing inpatient expenses for diseases with highly complex conditions and diseases with urgent conditions, but it has a significant effect in reducing inpatient expenses of diseases with less complex and less urgent conditions. Our study offers implications that the differences in condition’s complexity and urgency among diseases would lead to different impacts of hospital competition, which would be given full consideration when designing the pro-competition policy in the healthcare delivery system to achieve the desired goal.

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